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Le stenting carotidien par voie cervicale. Une technique simple ? Pour les cas difficiles ? JM CARDON Hopital prive les franciscaines nimes. RISQUE CLINIQUE CAS. Criteres cliniques : AVC.

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le stenting carotidien par voie cervicale
Le stenting carotidien par voie cervicale

Une technique simple ?

Pour les cas difficiles ?

JM CARDON

Hopital prive les franciscaines

nimes

risque clinique cas
RISQUE CLINIQUE CAS
  • Criteres cliniques : AVC
risque cerebral cas
RISQUE CEREBRAL CAS

criteres anatomiques

ICSS substudy

124 CAS avec IRM pre/post

Transfemoral+filtre distal

50% nouvelles lesionsischemiques

cas risque anatomique
CASRISQUE ANATOMIQUE

1363 CAS

754 CEA

Nouvelle lesion IRM

37%

Nouvelle lesion IRM

10%

Metaanalyse KARSTRUP STROKE 2008

IRM PRE ET POST CAS /CEA

risque cerebral a la navigation quel territoire
RISQUE CEREBRAL A LA NAVIGATIONQUEL TERRITOIRE ?

ZHU : j vascsurg 2011

  • Audit neuro + DWI pre /post : 30 CAS

1 minor stroke

131 nouvelles lesionsischemiques IRM

  • Ipsi : 83,1% Contro : 16,9%
  • Territoire : c m : 91,6% ipsi et contro

c p : 6,1%

cerebelleuse: 2%

quel risque a cas
QUEL RISQUE A CAS ?

Grossetti : acta chirbelg 2011

50 CAS: pas de predilatation ;filtre distal

HR color flow mapping

TCD intra op + 12 H post op

DWI pre/post

4 test psycometriques

Audit neuro

slide7

Minor stroke : 4%

  • hits per op : 100%
  • Hits post op : 10%
  • Nouvelles lesionsischemiques : 44%
  • Diminution capacites cognitives : 36%
dw mri
DW MRI

Although the fundamental issues of the nature of the embolic particles, precise mechanisms of cerebral injury, and effective prevention remain debated and unclear, recent reports have provided substantial evidence of memory loss, cognitive decline, and dementia related to these so-called silent infarcts.

Clinical Significance of New White Lesions

Gress DR. JACC 2012.

dw mri1
DW MRI

In population-based studies, a strong association has been found between MRI lesions and prevalent cognitive dysfunction and dementia.

The more extensive the MRI lesions, the more severe is the observed cognitive impairment.

Clinical Significance of White Lesions

Sun X. JACC 2012;60:791–7.

en consequence pendant cas
En consequencependant cas
  • IL EXISTE UN RISQUE CLINIQUE ET ANATOMIQUE
  • LES HITS ( embol) ONT UNE CONSEQUENCE ANATOMIQUE:PETIRES LESIONS ISCHEMIQUES A L’IRM
  • MEME SI PAS D’AVC :DIMINUTION DES FONCTIONS COGNITIVES
patients a risque pour la navigation
Patients a risque pour la navigation

ANATOMIE DIFFICILE

  • en amont

Arche bovine

Crosse aortique type 3

Angulation CPG sur la crosse

Tortuosites CP

  • La bifurcation

naissance horizontale

  • En aval

boucles et kingking

patient a risque pour la navigation lesion emboligene
Patient a risque pour la navigation:lesionemboligene
  • Crosse aortique : calcification

debrisatheromateux

thrombus

  • Bifurcation carotidienne

Gros amas calcaire

Trombus

Hemmoragieintraplaque

  • Lesions tandem
patient a risque pour la navigation age
Patient a risque pour la navigationage
  • Meta analyse Bonati :eur j vasc 2011

eva3s spaceicss : 3433 patients

TCMM a 120 jours : 8,9%

age seul subgroup significatif:

age<70 ans:5,8%

age>70 ans:12%

il existe donc un risque a la navigation
Il existe donc un risque a la navigation
  • Navigation dans la crosse =risque AVC homo,contro et post
  • Navigation dans CP et dans CI= risque AVC homolateral
  • Franchissement de la lesion par le filtre est dangereux
  • Lesionsintimales sur CI distales liees au filtre= HITS
transfemoral cas low risk of mi and cni but increased peri procedural stroke risk
Transfemoral CASLow risk of MI and CNI but increased peri-procedural stroke risk

1N Engl J Med 2010;363:11-23. 2 Stroke. 2011;42:00-00.

comment proteger
Comment proteger?

S macdonald : j cardiovascsurg 2010

Ballon occlusif,filtrationdistale,flow reverse

Arrete les gros debris mais environ 100 000 microparticules pendant 1 CAS protegee

Ballon occlusif↓↓ hits

Distal filter↑↑hits embolisationcontrollee

Flow reverse stop hits

slide17

Direct Carotid Revascularization

CEA

Transfemoral CAS

Potential Benefits

Neuroprotection

Minimally Invasive

Decreased Stroke Risk

Decreased MI Risk

Decreased CNI Risk

Local Anesthesia

Fast

  • Advantages
    • Minimally invasive
    • Local anesthesia
    • Durable
  • Disadvantages
    • Access-related stroke
    • Excess stroke risk
    • Asymptomatic brain infarction
  • Advantages
    • Complete neuroprotection
    • Direct access
    • Durable
  • Disadvantages
    • More invasive, general anesthesia
    • Myocardial infarction risk
    • Cranial nerve injury
    • Wound complications
flow reverse est la solution
Flow reverse est la solution
  • Par abord femoral ne regle pas le probleme car l embolisation peut se produire lors de la montee du système dans la carotide primitive et lors de son retrait
  • Par abord trans cervical tous les problemes sont regles:

comme CAS: risque corronaire minimal

comme CEA: risque cerebral minimal

dw mri prospective studies
DW MRIProspective Studies

1 J Am Coll Cardiol. 2012 Jan 19 [Epub ahead of print].

2 Lancet Neurol. 2010 Apr;9(4):353-62.

3 P Rubino, 2011 EuroPCR.

le flow reverse avec abord carotidien
Le flow reverse avec abord carotidien

Abord au cou sous AL

Flow reverse home made

Stenting sur guide 0,14

slide21

Avantages

Pas de navigation

Pas de franchissement de

la lesion sans protection

couts

  • Inconvenients

Hemodetournementcerebral

CI si calcification CP

Exposition des mains

2 techniques
2 techniques

Custom

Silk road

slide23

TECHNIQUE

ECHOGRAPHIE PRÉOPÉRATOIRE:

slide24

TECHNIQUE

INCISION:

slide25

TECHNIQUE

DISSECTION VEINEUSE ET ARTÉRIELLE:

slide26

TECHNIQUE

PONCTION VEINEUSE:

slide27

TECHNIQUE

PONCTION VEINEUSE:

slide28

TECHNIQUE

PONCTION ARTERIELLE:

HÉPARINISATION SISTÉMIQUE:

slide29

TECHNIQUE

CONNEXION:

slide30

TECHNIQUE

FISTULE ARTERIO-VEINEUSE:

slide31

TECHNIQUE

PASSAGE DE LA LÉSION:

slide32

TECHNIQUE

LIBÉRATION DU STENT

ET BALONEMENT:

slide33

TECHNIQUE

CONFIRMATION ARTERIOGRAPHIQUE:

slide34

TECHNIQUE

SUTURE DE L’ARTÉRIOTOMIE:

slide35

TECHNIQUE

FERMETURE DE L’INCISION:

resultats
resultats
  • Criado : j vascsurg 2004 : 50 patients
  • Chang : j vascsurg 2004 : 21
  • Matas : j vascsurg 2007 : 62
  • Alvarez : j vascsurg 2008 : 81 > 80 ans
  • Fast cas registre : 65
transcervical carotid revascularization with flow reversal in the literature
Transcervical Carotid RevascularizationWith Flow Reversal In The Literature

J Vasc Surg 2004;40:92-7

Criado E. VEITH 2010.

resultats1
resultats
  • TCMM=0 a 5%
  • IDM= 0%
  • Intolerance : 7%
  • Complication locale : 2%
  • HITS : 6%
  • Nouvelles lesions DWI :16,7%
silk road
Silk road
  • Large bore flow reversal circuit
  • Flow controller with stop, HI and LO flow
  • 8F Transcervical Arterial Sheath
  • 8F Venous Return Sheath
slide43

PROOFFirst In Man Results

Pinter L. JVS 2011;54:1317-23.

proof safety results
PROOFSafety Results

1One subject developed a GI bleed 2 days post procedure

conclusion
Conclusion
  • Risque cerebralequivallent a CEA
  • Riquecorronarienequivallent a CAS
  • Cela va-t-il reconcilier chirurgien et CAS?
  • Dans notre practique 10% des CAS mais a barcelone 100%
  • Silk road : la solution ?
summary carotid revascularization with michi neuroprotection system
SummaryCarotid Revascularization With MICHI Neuroprotection System
  • The MICHI™ Neuroprotection System was shown to be a safe and feasible method for carotid revascularization
  • Low rate of MI and cranial nerve Injury is commensurate with transfemoral CAS and shows improvement over CEA
  • Low rate of stroke/death and new DWI lesions is commensurate with CEA and shows improvement over transfemoral CAS
  • Larger, multi-center experience is underway to confirm initial results
atherosclerotic aortic lesions
Atherosclerotic Aortic Lesions

N=59 Patients Undergoing CAS

In patients with all three AA characteristics, mean number and volume of embolic brain lesions was significantly greater compared with other patients.

Faggioli G. J Vasc Surg 2009;49:80-5.

Can Increase the Risk of Cerebral Embolization during CAS In Patients With Complex Aortic Arch Anatomy

slide53

Transcervical CASVs. Transfemoral CAS

“The low 12.9% incidence in the transcervical group is comparable to the best series of CEA and a great improvement over the results of CAS with distal filters.”

“The results of CAS are clearly influenced by the access route and cerebral protection methods…..The risk of embolic complications with transfemoral carotid stenting is related to instrumentation of the arch and proximal supra-aortic trunks, crossing of the carotid lesion without protection, and use of distal filter protection devices of questionable benefit.”

Leal I. JVS 2012.

slide56

Gupka :j vascsurg 2011

TCD 33 patients:

mean hits ipsi : 14 CAS+DF : 320

5 CAS+FR : 185

14 CEA : 15

  • Periode hits pendant pour DF

avant pour FR

apres pour CEA

cas in crest
CAS in CREST

Gray WA. Circulation. 2012;125:2256-2264

Experience & Learning Curve

cas procedural evolution
CASProcedural Evolution

2010

2003

Clair D. Cath Cardiovasc Int 77:420–429 (2011).

slide60
FAQ

How do you manage intolerance?

Intolerance can be managed. There are many options:

  • Supplemental O2
  • Increase blood pressure
  • Expeditiously complete procedure and restore antegrade flow
  • Manage flow: intermittently switch to lo flow or stop flow
  • Intermittently restore antegrade flow by unclamping

In the PROOF study, 5 of 65 (7.7%) patients experienced investigator-reported intolerance. All patients successfully received a stent and intolerance resolved without clinical sequelae. Intolerance was not associated with post-procedure DWI lesions.

One of the benefits of direct carotid revascularization is the ability to perform a very quick procedure and limit the duration of CCA clamping and flow reversal (in contrast to CEA).